Provider Demographics
NPI:1326128224
Name:BREWER, DOUGLAS WAYNE
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:WAYNE
Last Name:BREWER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 E CORPORATE DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2951
Mailing Address - Country:US
Mailing Address - Phone:208-846-8400
Mailing Address - Fax:
Practice Address - Street 1:280 E CORPORATE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2951
Practice Address - Country:US
Practice Address - Phone:208-846-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCH1A1123111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation